Written by: Michael Parker
Initial Evaluations on Disputed Claims
One of my many pet peeves in this business is the jurisprudential/case law requirement that an employer/payor is obligated to pay for an employee’s initial evaluation with the doctor to whom their lawyer has sent them, even if the claim is disputed or there is no evidence that an accident happened at work. If you read the Compensation Act, an employer/payor is responsible for payment of indemnity benefits and reasonable and necessary medical care if an employee receives personal injury by accident arising out of and in the course of his/her employment.
Any rational person reading this requirement would agree that before an employer/payor can be required to pay indemnity benefits or approve medical treatment that the injured employee must prove there was an accident, that he/she suffered personal injury and that the accident/injuries arose in the course of their employment. There is no statutory requirement that an employer/payor approve or pay for medical treatment prior to the claimant proving that an accident occurred during the course of his/her employment and there was an injury resulting from the accident.
The lack of statutory authority has never been an impediment some Courts and the requirement for an employer/payor to pay for an initial evaluation with the doctor the lawyer has picked for the claimant to see is no exception. In Scott v Packaging Corporation of America, the Court awarded penalties and attorney fees when the employer failed to approve an initial evaluation with lawyer’s choice of doctors in a claim that the employer argued was not compensable. Thus, without having to prove an accident with injuries resulting from the course and scope of his employment, Scott’s employer was required to pay for him to see a doctor that his lawyer had picked but also had to pay penalties and attorney fees for failing to do so.
For now, if you are asked to approve an initial evaluation by the claimant’s choice of doctor the case law requires that you do so even if the claim is disputed and there is no proof of an accident. My recommendation is that you approve an initial evaluation but make it clear it is just an evaluation and no diagnostic testing is authorized and then deny any future 1010’s seeking approval for medical treatment.
Wishing everyone a Merry Christmas as the holiday season is upon us.